Provider Demographics
NPI:1861935173
Name:BOLL, JACOB EDWARD (DC)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:EDWARD
Last Name:BOLL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 JEFFERSON RIVER RD
Mailing Address - Street 2:
Mailing Address - City:THREE FORKS
Mailing Address - State:MT
Mailing Address - Zip Code:59752-9765
Mailing Address - Country:US
Mailing Address - Phone:712-260-0831
Mailing Address - Fax:
Practice Address - Street 1:25 JEFFERSON RIVER RD
Practice Address - Street 2:
Practice Address - City:THREE FORKS
Practice Address - State:MT
Practice Address - Zip Code:59752-9765
Practice Address - Country:US
Practice Address - Phone:712-260-0831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60706123111N00000X
MTCHI-CHI-LIC-4595111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1437668449Medicaid